A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Check the client's distal pulses in both legs.

Keep the client overnight.

Keep the client on bed rest for 12 hr.

Restrict the client's oral fluids.

Answer and Explanation

The Correct Answer is A

A. Check the client's distal pulses in both legs:

Checking the client's distal pulses in both legs is crucial to ensure that there is adequate blood flow and no signs of arterial occlusion or complications from the catheterization. This is an important assessment to detect potential vascular complications, such as a hematoma or an arterial blockage.

B. Keep the client overnight:

Keeping the client overnight is not typically required for all cardiac catheterization procedures. The need for an overnight stay depends on the individual case and any complications or comorbidities. Routine catheterizations often allow for discharge on the same day with appropriate monitoring.

C. Keep the client on bed rest for 12 hr:

Keeping the client on bed rest for 12 hours is excessive. Typically, bed rest is required for 2 to 6 hours following the procedure to allow the puncture site to stabilize and reduce the risk of bleeding. The exact duration of bed rest depends on the approach used and the patient's condition.

D. Restrict the client's oral fluids:

Restricting the client's oral fluids is generally not appropriate. In fact, increasing fluid intake is often encouraged to help flush out the contrast dye used during the procedure and to prevent renal complications. Monitoring for fluid balance is important, but outright restriction is not typically indicated unless there is a specific medical reason.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. “They’ll protect your legs and heels from skin breakdown.”: While antiembolism stockings can provide some degree of protection against skin breakdown due to their snug fit, this is not their primary purpose. Their main function is to improve circulation and prevent blood clots, not to protect the skin.

B. “They’ll make it easier for you to do leg exercises after your surgery.”: Antiembolism stockings do not directly facilitate leg exercises. While they can help improve circulation which might indirectly aid in recovery, their primary purpose is to prevent the formation of blood clots in the lower extremities.

C. “They’ll improve your circulation to keep blood from pooling in your legs.”: This is correct. Antiembolism stockings, also known as compression stockings, are designed to apply pressure to your lower legs, helping to maintain blood flow and reduce discomfort and swelling. They can help prevent deep vein thrombosis (DVT), a type of blood clot that’s most common in the deep veins of your legs.

D. “They’ll help keep you warm immediately after your surgery.”: While antiembolism stockings might provide some warmth due to their material, this is not their primary function. Their main purpose is to improve circulation in the legs and prevent blood clots.

A. Document the rhythm as normal. B. Start cardiopulmonary resuscitation (CPRL C. Prepare the patient for cardioversion. D. Prepare to administer atropine

Correct Answer is B

Explanation

(A) Document the rhythm as normal: Asystole is a serious condition characterized by a flatline ECG, indicating no electrical activity in the heart. It is not a normal rhythm and requires immediate intervention.

(B) Start cardiopulmonary resuscitation (CPR): This is the most appropriate initial action. Asystole is a life-threatening condition that requires immediate intervention. The first step should be to start CPR and call for help.

(c) Prepare the patient for cardioversion: Cardioversion is typically used to treat conditions where the heart is beating irregularly (arrhythmias), but not when there is no electrical activity at all (asystole).

(D) Prepare to administer atropine: Atropine is sometimes used in the treatment of bradycardia (slow heart rate), not asystole. In the case of asystole, epinephrine is more commonly administered during resuscitation efforts.

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